Review of Seminar Lunchtimethe Effectiveness of Dac Com

Review of Seminar Lunchtimethe Effectiveness of Dac. Com Title Presentation: Date. July 2008 30 th By: Name Ian Bonny 1

Agenda Slide title should not be larger than Palatino Linotype 24 pt. Scope of Review and the Journey So Far Dac. Com Structure Dac. Com Governance Dac. Com Strategic Direction Relationship with PCT Leadership Prescribing – A Success Story Summary 2

Scope of Review » Through a series of stakeholder interviews, to: › › » Outcomes were to: › › › Page 2 3 Review Dac. Com structure Review Dac. Com roles and responsibilities Review Dac. Com decision-making process Include brief comparison Dac. Com against neighbouring commissioning bodies Recommend any structural changes Recommend any changes to corporate governance Recommend any changes to roles and responsibilities

Stakeholder Interviews » » 4 Twenty stakeholder interviews conducted These included › Clinicians from Dac. Com › Managers from Dac. Com › External stakeholders such as Patient’s Representative and PCT staff › Clinicians from St. AHCom and Wat. Com › Managers from St. AHCom and Watcom

The Journey so far » » Commissioning environment in Dac. Com different from that in St Albans and Watford › Not a level playing field » Dac. Com has played full part across West Herts › West Herts Leads › LMC/PBC Liaison › Governance sub-committee › Clinical conclave » Dac. Com has taken responsibility for its actions by commissioning this review » 5 Have achieved a great deal from a standing start › Services are being commissioned › Dac. Com played full part in wiping out budget deficit › Despite no previous history of collaborative working, 19 individual Practices, across a relatively large geographical area, are on the whole working well together › Strong financial management › Small, hard working and dedicated group leading activities Opportunity to regroup and address the new challenges confronting Dac. Com

Dac. Com Structure » » Use of Locum cover › Clinicians to give up Practice sessions › Perception that it is driven by financial considerations at expense of well -being of staff » Clinician or Management led? » 6 Executive decision-making body too large and too unwieldy › Representative rather than functional › Too easy to block decisions PCT support staff › Fill the current Relationship Manager vacancy

Changes to Dac. Com Structure » » 7 Develop role of Chief Executive/Programme Manager › Lead strategy development process › Lead business case development › Does not need to be full time › Must be clinician or at least strong clinical background › Must have good business skills Introduce smaller Operating Board (approx six members) › Will lead on strategy development, developing business cases, monitoring & implementation, financial management & reporting › Led by Chief Executive › Board members primarily clinical › Accountable to Executive Committee › Could also include PCT Business Manager

Dac. Com Governance » One big issue - lack of clarity › › How can they be removed? › How are additional people elected/co-opted? › 8 How long do they serve for? › » How are people elected to Executive Committee? When is the AGM? Is lack of knowledge and awareness down to the Executive Committee or to individual staff not making the effort to keep informed?

Dac. Com Governance » » Original Executive Committee and Practice Agreement/Constitution both delivered what was required at outset of practice based commissioning » Commissioning world is now very different place » Re-elect Executive Committee over the next two years › Review Executive Committee roles and length of term › Develop future timetable for re-election » 9 Next Steps? Re-draft the Practice Agreement/Constitution › Will need to reflect any Chief Executive and Operating Board positions

Dac. Com Strategic Direction » » Commissioning strategy is felt to be piecemeal and seen as knee-jerk reaction to PCT demands » Any developed strategy does not have the buy-in of Dac. Com people › People feel excluded from the process › A feeling that it does not accurately reflect local needs › Does not fully meet needs of PCT › Tough balancing act! » 10 The perception is of a lack of strategic direction Too late to revisit current plan, but now is the time to start planning for 2009/2010 › Process must be inclusive and consultative › Outcomes must define what Dac. Com is about › Consider externally facilitated workshops

CATS » » However, political wind is firmly behind CATS › Dac. Com approach is seen as obstructive › Dac. Com being marginalised › PCT under great pressure to implement CATS › St. AHCom and Wat. Com implementing CATS has only served to weaken the Dac. Com position further » 11 CATS may well be the worst commissioning idea to come out of the DH in some time › Evidence suggests that money is not being saved and patient access to hospitals being reduced Pilot one CATS › Shape it to what Dacorum wants › If it works, great › If not, shape it into something that will

Relationship with PCT » » Do you want to repair the relationship? › Truth is, in practical terms you have no choice but to repair it › Consequences of not will be continued marginalisation and isolation » 12 Current relationship has broken down › Described as antagonistic › Characterised by lack of trust and clarity around commissioning agendas › Many issues seen as personal rather than commissioning based › Perception is St. AHCom and Wat. Com enjoy constructive relationship due to history and favouritism from PCT Basic commissioning agenda comes from PCT › Dac. Com cannot influence agenda from outside › Need to understand problems of PCT

Relationship with PCT » » Darzi Centre and reconfiguration of Hemel Hempstead GH › Unless you engage the PCT these will be ‘done to you’ rather than you leading the process › Already recognising this with the Darzi Centre » Recruit PCT Business Support Manager › Not a ‘spy in the camp’ but valuable resource that will stand up to PCT on your behalf » 13 Must become more politically astute › Must put time, effort and resource into playing the ‘political game’ › Understand that PCT agenda is politically driven › Spend time at PCT Head Office › Schedule monthly meetings with Andrew Parker and Suzanne Novak You must make the first move with the PCT!

Leadership » » Clinical leadership › Not criticism of technical skills › Perceived lack of widespread commitment to commissioning › Dac. Com does not have organisation-wide entrepreneurial spirit › Dac. Com does not have organisation-wide “can do” attitude › Too much expected of too few people how have delivered but at what personal cost? » 14 Perceived lack of leadership Need single point of leadership › Appoint Chief Executive/Programme Manager › Single person to drive Dac. Com commissioning agenda › Engage all Practices › Authority to make things happen › Accountable to Executive Committee

Prescribing » » Learn the lessons › Clear strategic direction › Clear clinical leadership › Devoted time, effort and resource to be successful › Widespread buy-in from Practices › Clear incentives › Strong external relationships ‒ Local hospitals ‒ PCT » 15 What a success story! Apply this learning organisation-wide

Summary [1] » » Develop smaller ‘Operating Board’ » Review current Executive Committee constitution » Re-elect Executive Committee members over next two years » Engage all Practices in strategy development for 2009/2010 » Pilot a CATS » 16 Develop Chief Executive/Programme Manager role Play the ‘political game’ and repair the relationship with the PCT

Summary [2] » » Seize the initiative on the Darzi Centre and lead the reconfiguration of Hemel Hempstead GH » Develop a strategy to engage all Dacorum Practices in the concept of commissioning » Develop a wider clinical leadership team » Clinical leaders to give up sessions and use Locum cover on more regular basis » 17 Recruit the PCT Business Support Manager Learn the lessons from the prescribing project and apply them